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The AGREE Collaboration. Appraisal of Guidelines for Research & Evaluation (AGREE) Instrument.
Burgers J, Fervers B, Haugh M. 'Guideline appraisal ? an international viewpoint' February 2004.
[External Link]

AGREE is the acronym for "Appraisal of Guidelines Research and Evaluation". The purpose of the AGREE Instrument is

  • To provide a systematic framework for appraising the quality of clinical guidelines
  • To help policymakers decide which guideline to recommend for use in practice
  • To help guideline developers follow a structured and rigorous methodology
  • To help health care providers assess guidelines before adopting recommendations in practice

The AGREE Instrument consists of 23 key items organized in six domains. Each domain is intended to capture a separate dimension of guideline quality.

Six Domains

  1. Scope and purpose (items 1-3) is concerned with;
    • the overall aim of the guideline
    • the specific clinical questions
    • the target patient population
  2. Stakeholder involvement (items 4-7)
    • includes individuals from all relevant professional groups
    • patient's vies and preferences have been sought
    • target users are clearly defined
    • guidelines has been piloted among target users
  3. Rigour of development (items 8-14)
    • systematic methods were used to search for evidence
    • the criteria for selecting the evidence are clearly described
    • the methods used for formulating the recommendations are clearly described
    • the health benefits, side effects and risks have been considered in formulating the recommendations
    • there is an explicit link between the recommendations and the supporting evidence
    • the guideline has been externally reviewed by an expert panel prior to publication
    • a procedure for updating the guideline is provided
  4. Clarity and presentation (items 15-18)
    • the recommendations are specific and unambiguous
    • the different options for management of the conditions are clearly presented
    • key recommendations are easily identifiable
    • the guideline is supported with tools for application
  5. Applicability (items 19-21)
    • the potential organizational barriers in applying the guideline have been discussed
    • the potential costs implications of applying the recommendations have beed considered
    • the guideline presents key review criteria for monitoring and/or audit purposes
  6. Editorial Independence (items 22-23)
    • the guidelines is editorially independent from the funding body
    • conflicts of interest of guideline development members have been recorded

Response Scale

Each item is then rated on a 4-point scale from "Strongly Agree to Strongly Disagree" depending upon the extent to which an item has been fulfilled.

Strongly Agree Strongly Disagree
4 3 2 1


Standardized guideline domain scores are calculated by:

  • summing up all the scores of individual items in a domain
  • and by standardizing the total as a percentage of the maximum possible score for that domain


Item 1 Item 2 Item 3 Total
Appraiser 1 2 3 3 8
Appraiser 2 3 3 3 10
Appraiser 3 2 4 3 9
Appraiser 4 2 3 4 9
Total 9 13 14 36

Max. possible score = 4 (strongly agree) × 3 (items) × 4 (appraisers) = 48
Min. possible score = 1 (strongly disagree) × 3 (items) × 4 (appraisers) = 12

The standardized domain score will be:

(score possible min. - score possible max.) / (score possible min. - score obtained)
= (36 - 12) / (48 - 12)
= 24 / 36
= 0.67 × 100
= 67%